* required for saving **required for completion Facility ID:
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Event #:
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*Patient ID:
| Social Security #:
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Secondary ID:
| |
Patient Name, Last: First: Middle:
|
*Gender: F M Other
| *Date of Birth:
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Ethnicity (Specify):
| Race (Specify):
|
*Event Type: PNEU
| *Date of Event:
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*Post-procedure PNEU: Yes No
| Date of Procedure:
|
NHSN Procedure Code:
| ICD-9-CM Procedure Code:
|
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module □ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
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*Date Admitted to Facility:
| *Location:
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Risk Factors
|
*Ventilator: Yes No Location of Device Insertion:_________ Date of Device Insertion: ___/___/______ *For NICU only: Birth weight: ____________grams
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Event Details
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*Specific Event: □ PNU1 □ PNU2 □ PNU3 *Immunocompromised: Yes No
|
*Specify Criteria Used: (check all that apply) X-Ray
□ New or progressive and persistent infiltrate □ Consolidation □ Cavitation □ Pneumatoceles (in ≤1 y.o.)
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Signs & Symptoms
□ Fever □ Leukopenia or leukocytosis □ Altered mental status (in ≥70 y.o.) □ New onset/change in sputum □ New onset/worsening cough, dyspnea,
tachypnea
□ Rales or bronchial breath sounds† □ Worsening gas exchange □ Hemoptysis □ Pleuritic chest pain □ Temperature instability □ Apnea, tachycardia, nasal flaring with
retraction of chest wall or grunting
□ Hypothermia □ Wheezing, rales, or rhonchi† □ Cough □ Bradycardia or tachycardia
| Laboratory
□ Positive blood culture □ Positive pleural fluid culture □ Positive quantitative culture from LRT specimen □ ≥5% BAL cells w/bacteria □ Histopathologic exam w/ abscess formation,
positive quantitative culture of lung parenchyma, or lung parenchyma invasion by fungal hyphae
□ Positive culture of virus or Chlamydia □ Positive detection of viral antigen or antibody □ 4-fold rise in paired sera for pathogen □ Positive PCR for Chlamydia or Mycoplasma □ Positive micro-IF test for Chlamydia □ Positive culture or micro-IF of Legionella spp □ L pneumophila serogroup 1 antigens in urine □ 4-fold rise in L pneumophila antibody titer □ Matching positive blood & sputum cultures w/ Candida spp □ Fungi or Pneumocytis carinii from LRT specimen
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*Secondary Bloodstream Infection: Yes No
|
**Died: Yes No
| PNEU Contributed to Death: Yes No
|
Discharge Date:
| *Pathogens Identified: Yes No *If Yes, specify on pages 2-3.
|
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 32 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.111 (Front) Rev 3, v6.4
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